bmj open€¦ · 7. chi mei medical centre, department of psychiatry, tainan, taiwan 8. st john’s...

For peer review only

Discrimination in the workplace, reported by people with

major depressive disorder: Cross-sectional study in 35

countries.

Journal: BMJ Open

Manuscript ID bmjopen-2015-009961

Article Type: Research

Date Submitted by the Author: 17-Sep-2015

Complete List of Authors: Brouwers, Evelien; Tilburg University, School of Social & Behavioral Sciences, Tranzo Mathijssen, Jolanda; Tilburg University, School of Social & Behavioral Sciences, Tranzo Van Bortel, Tine; King’s College London, Institute of Psychiatry Knifton, Lee; Mental Health Foundation, Wahlbeck, Kristian; National Institute for Health and Welfare, Audenhove, Chantal; Katholieke Universiteit Leuven, LUCAS Kadri, Nadia; Ibn Rushd University, Psychiatric Center Chang, Chih-Cheng; Chi Mei Medical Centre, Department of Psychiatry Goud, Ramakrishna; St John’s Medical College Hospital, St John’s National Academy of Health Sciences Ballester, Dinarte; Sistema de Saúde Mãe de Deus, Tofoli, Luis Fernando; Universidade Federal do Ceara, Bello, Ricardo; Hospital Universitario de Caracas, Monteiro, Maria Fatima; Associacao para o Estudo e Integracao Psicossocial, Zaeske, Harald; Heinrich-Heine Universitaet, Rheinische Kliniken Dusseldorf Milacic, Ivona; University of Belgrade, Faculty for Special Education and Rehabilitation, Ucok, Alp; Istanbul University, Faculty of Medicine, Department of Psychiatry Bonetto, Chiara; University of Verona, Department of Public Health and Community Medicine, Section of Psychiatry Lasalvia, Antonio; University of Verona, Department of Public Health and Community Medicine, Section of Psychiatry Thornicroft, Graham; Kings College London, Institute of Psychiatry van Weeghel, Jaap; Tilburg University, School of Social & Behavioral Sciences, Tranzo

<b>Primary Subject Heading</b>:

Mental health

Secondary Subject Heading: Occupational and environmental medicine, Rehabilitation medicine

Keywords: Adult psychiatry < PSYCHIATRY, Depression & mood disorders < PSYCHIATRY, OCCUPATIONAL & INDUSTRIAL MEDICINE

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Discrimination in the workplace, reported by people with major depressive disorder:

Cross-sectional study in 35 countries.

Brouwers EPM1, Mathijssen J

1., Van Bortel T

2., Knifton L.

3, Wahlbeck K.

4, Van Audenhove C

5,

Kadri N6, Chang Ch

7, Goud BR

8, Ballester D

9, Tófoli LF

10, Bello R

11, Jorge-Monteiro MF

12,

Zäske H13

, Milaćić I14

, Ucok A15

, Bonetto C16

, Lasalvia A16

, Thornicroft G.2; Van Weeghel J.

1;

and the ASPEN/INDIGO Study Group*

1. Tilburg University, department Tranzo, The Netherlands

2. King’s College London, Institute of Psychiatry, London, UK

3. Mental Health Foundation, Glasgow, UK

4. National Institute for Health and Welfare, Vasa, Finland

5. Katholieke Universiteit Leuven, Leuven, Belgium

6. Ibn Rushd University Psychiatric Centre, Casablanca, Morocco

7. Chi Mei Medical Centre, Department of Psychiatry, Tainan, Taiwan

8. St John’s Medical College Hospital, St John’s National Academy of Health Sciences,

Bangalore, India

9. Sistema de Saúde Mãe de Deus, Porto Alegre, Brazil

10. Universidade Federal do Ceara, Campus Sobral, Brazil

11. Hospital Universitario de Caracas, Caracas, Venezuela

12. Associacao para o Estudo e Integracao Psicossocial, Lisbon, Portugal

13. Heinrich-Heine Universitat Dusseldorf, Rheinische Kliniken Dusseldorf, Germany

14. Faculty for Special Education and Rehabilitation, Belgrade, Serbia

15. Foundation of Psychiatry Clinic of Medical Faculty of Istanbul, Istanbul, Turkey

16. Department of Public Health and Community Medicine, Section of Psychiatry,

University of Verona, Verona, Italy

Corresponding author:

Evelien P.M. Brouwers, PhD

Tilburg University, School of Social and Behavioral Sciences, Department Tranzo, The

Netherlands. P.O. Box 90153, 5000 LE Tilburg. Tel: +31 (0)13 4662962

[email protected]

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Abstract

Objective

Whereas employment has shown to be beneficial for people with Major Depressive Disorder

(MDD), across different cultures, employers’ attitudes have shown to be negative towards

workers with MDD. This may form an important barrier to work participation. Today, little is

known about how stigma and discrimination affect work participation of workers with MDD,

especially from their own perspective. We aimed to assess, in a working age population

including respondents with MDD from 35 countries: (1) if people with MDD anticipate and

experience discrimination when trying to find or keep paid employment; (2) if participants in

high, middle and lower developed countries differ in these respects; and (3) if discrimination

experiences are related to actual employment status (i.e. having a paid job or not).

Method

Participants in this cross-sectional study (N=834) had a diagnosis of MDD in the previous 12

months. They were interviewed using the Discrimination and Stigma Scale (DISC-12).

ANOVAS and generalized linear mixed models were used to analyze the data.

Results

Overall, 62.5% had anticipated and/or experienced discrimination in the work setting. In

very high-developed countries almost 60% of respondents had stopped themselves from

applying for work, education or training because of anticipated discrimination. Having

experienced discrimination was independently related to unemployment.

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Conclusions

Across different countries and cultures, people with MDD very frequently reported

discrimination in the work setting. Effective interventions are needed to enhance work

participation in people with MDD, focusing simultaneously on decreasing stigma in the work

environment and on decreasing self-discrimination by empowering workers with MDD.

Keywords: discrimination, stigma, depression, mental, employment, work, workplace,

human development index

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Strengths and limitations

• Depression is the leading cause of disability worldwide, and for this study

respondents with major depressive disorder from as many as 35 countries were

interviewed.

• This study is examines the under-researched yet substantial problem of

discrimination as a barrier for work participation of people with MDD.

• Interviews were used to gather direct self-reports rather than hypothetical scenarios

or vignettes, which is often done in research on stigma and discrimination

• Limitations are the cross sectional design of the study, and the fact purposive

sampling was used to recruit participants, which limits the generalizability of the

results.

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Introduction

Employment has many benefits that can contribute to the recovery of people with

mental health problems 1, 2

. However, in many countries participation and re-integration of

people with mental health problems in the workforce is problematic 3, 4

. Several factors

cause this, some of which are related to the individual, and some to the environment. An

important barrier for full occupational participation and successful vocational integration is

the stigma that is associated with mental health problems5. Stigma is a mark or sign of

disgrace usually eliciting negative attitudes to its bearer and can be seen as a problem

associated with knowledge (ignorance), attitudes (prejudice) and behavior (discrimination)6.

Several studies have shown that although some cultural differences may exist7, overall

employers in many countries commonly express a range of concerns about hiring a potential

employee with mental health problems 8-10

. Concerns reported include the belief that

people with mental health problems have limited productivity and job performance,

especially in tasks requiring cognitive skills 8, 11

, that they are unreliable and might pose

threats to the safety of other employees, customers or themselves11

, or behave in a strange

and unpredictable manner, and that there is potential for symptom relapse 8. In addition,

the anticipation of discrimination by people with MDD may lead them not to apply for a job,

in the expectation of failure or rejection.

Whereas most studies on mental health problems and discrimination in the

workplace have focused on severe mental disorders such as schizophrenia, very few have

focused on major depressive disorder (MDD)5. This is remarkable, as MDD is one of the

leading causes of the global burden of disease12

. It is one of the most prevalent of all causes

of disability 13, 14

and therefore an important public health problem. Across different

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countries and cultures stigma and discrimination form an important barrier to work

reintegration, although this topic has hardly been studied. In this context, the aim of this

study was to assess: (1) if people with MDD of working age anticipate and experience

discrimination because of their mental health problems when trying to find or keep paid

employment; (2) if people with MDD of working age from high, middle and lower developed

countries differ in this respect; and (3) if discrimination experiences when trying to find or

keep paid employment are related to present work status (i.e. having a paid job) in working

aged people with MDD.

Methods

Study design

Data were gathered as part of a larger study by the European Commission funded ASPEN

(Anti Stigma Program European Network) study and the INDIGO (International Study of

Discrimination and Stigma for Depression) research network15

. In a cross-sectional survey,

people with a clinical diagnosis of major depressive disorder were interviewed in 35

countries. The ASPEN countries included Belgium, Bulgaria, England, Finland, France,

Germany, Greece, Hungary, Italy, Lithuania, The Netherlands, Portugal, Romania, Scotland,

Slovakia, Slovenia, Spain and Turkey. The countries participating through the INDIGO

network included Australia, Brazil, Canada, Croatia, Czech Republic, Egypt, India, Japan,

Malaysia, Morocco, Nigeria, Pakistan, Serbia, Sri Lanka, Taiwan, Tunisia and Venezuela.

The design of this study was intentionally pragmatic so that as many as possible low-

and middle-income countries could participate using only locally available resources,

because no external funding was available. Participants were recruited through local

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research staff, who were asked to identify people attending specialist mental health services

(either outpatient or day care in the public and private sectors) in the local area with a

clinical diagnosis of major depressive disorder in the previous 12 months. Each site was

asked to recruit at least 25 participants with MDD. As the present study focused on the

working age population, students (N=72) and retired respondents (N=168) were excluded

from the analyses. Full details of the method have been previously published15

.

Procedure

Data were gathered during face-to-face interviews in 2010, between January 1st

and

December 31st

. Inclusion criteria were (1) a clinical diagnosis of major depressive disorder

during the previous 12 months (single episode or recurrent), as based on the DSM-IV criteria;

(2) ability to speak and understand the main local language; and (3) aged 18 years or older.

Individuals who were receiving psychiatric in-patient care during recruitment were excluded.

The study was approved by the appropriate ethical review board at each study site. After

complete description of the study to the subjects, written informed consent was obtained.

Measures

Participants were assessed face-to-face by independent researchers not involved in the care

process using the standardized Discrimination and Stigma scale (version 12), a structured

interview for recording the discrimination experienced by an individual with a mental health

problem 16, 17

. The DISC-12 interview starts with the statement “Discrimination and stigma

occur when people are treated unfairly because they are seen as being different from others.

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This interview asks about how participants have been affected by discrimination and stigma

because of mental health problems”. The instrument consists of 32 questions, assessing

discrimination in several life domains, such as marriage, parenting, housing, and leisure. For

the present paper, only the items were that referred to discrimination in the work

environment are reported upon. For anticipated discrimination, the items used in this study

were: “Because of how others might respond to your mental health problem, have you

stopped yourself from applying for work?” and “Because of how others might respond to

your mental health problem, have you stopped yourself from applying for education and

training?”. For experienced discrimination, the items used were “Because of how others

might respond to your mental health problem, have you been treated unfairly in finding a

job?” and “Because of how others might respond to your mental health problem, have you

been treated unfairly in keeping a job?’. All questions were answered on a 4-point Likert

scale (0= not at all, 1= a little, 2=moderately, and 3= a lot).

For the second research question, consistent with the methodology of a previous

ASPEN/INDIGO paper18

, countries were divided into groups according to the Human

Development Index (HDI). The HDI is a summary measure of human development

established by the United Nations19

, which measures the average achievements of a country

in three basic dimensions of human development: (a) long and healthy life (operationalized

as life expectancy at birth), (b) access to knowledge, (i.e the mean number of years of

schooling), and (c) standard of living, (i.e. gross national income per capita). As data were

gathered in 2010, the HDI statistic of that year was used. Countries with a very high HDI

score were England, Australia, Finland, Germany, Canada, Italy, Portugal, Belgium, France,

Japan, Greece, The Netherlands, Scotland, Slovakia, Slovenia, Spain, Czech Republic, Taiwan

and Hungary. Countries with a high HDI score were Turkey, Malaysia, Brazil, Serbia, Bulgaria,

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Venezuela, Tunisia, Lithuania, Romania, and Croatia. As few countries had a low HDI, the

medium low and low HDI group were taken together as one group for the analyses. This

medium/low HDI group included Egypt, India, Morocco, Nigeria, Pakistan, and Sri Lanka.

Internalized stigma, one of the independent variables included in the analyses for

the third research question, was measured with the Internalized Stigma of Mental Illness

Scale (ISMI)20

. Internalized stigma refers to the inner subjective experience of stigma and its

psychological effects resulting from applying negative stereotypes and stigmatizing attitudes

to oneself. The ISMI is a 29-item instrument for self-rated assessment of the subjective

experience of stigma, with higher scores indicating higher internalized stigma. Here, the

total score on the ISMI was used.

Statistical analyses

All analyses were performed using SPSS 19. All p values were two-tailed with an accepted

significance level of 0.05. For the first research question, percentages of anticipated and

experienced discrimination were reported per country. For the second research question,

two separate ANOVAS were conducted, the first of which with anticipated discrimination as

the dependent variable and HDI level as the independent variable. A second ANOVA analysis

was conducted with experienced discrimination as the dependent variable and HDI level as

the independent variable. For the first and second research questions, answers to the

questions on anticipated and experienced discrimination were dichotomized into ‘No’ (“not

at all”) and ‘Yes’ (“a little”, “moderately”, “a lot”). For the third research question,

multivariable logistic regression analysis was performed, using work status as the

dependent variable, (defined as 0=no paid employment and 1=employed), and ten

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independent variables, including experienced discrimination. First, univariate analyses were

conducted including the following independent variables that were expected to be related

to job outcome: experienced discrimination, gender, age, ethnicity (i.e. belonging to an

ethnic minority), level of education, marital status, previous psychiatric treatment, age of

first contact with mental health services, internalized stigma (ISMI total score), and HDI.

Second, all variables that showed a significant relationship with the dependent variable on a

univariate level (P<0.05) were included in the multivariable logistic regression analysis.

Results

A total of 834 people with major depressive disorder across 35 different countries were

individually interviewed for this study. About half of all participants were married or

cohabiting, and two thirds of the participants were women. Characteristics of the sample

are shown in Table 1.

(Please insert Table 1 about here)

As shown in Table 2, for each separate question, about 40-50% of the participants indicated

that discrimination was not a problem for them. However, when looking at the 4 items

combined, about two thirds (62.5%) of the total sample reported anticipated and/or

experienced discrimination in the work setting due to their mental health problem. Almost

one third of participants indicated to have stopped themselves from applying for work

because of anticipated discrimination.

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Regarding the second research question, significant differences were found between

the groups with different HDI levels. Specifically, participants in countries with a very high

HDI reported significantly more often anticipated (Χ2 = 26.01 (df=2), p<0.01) and also

experienced (Χ2 = 7.25 (df=2), p<0.05) discrimination than participants in countries with

moderate/low HDI (see Figure 1). As can also be seen from this Figure, in all three groups

the anticipated discrimination scores were higher than the experienced discrimination

scores.

(Please insert Figure 1 about here)

Concerning the third research question, as can be seen in Table 3, several variables

were not related to work status on a univariate level (i.e. ‘belonging to an ethnic minority’,

‘marital status’, ‘age of first contact with mental health services’ and ‘HDI’). Results from the

multilevel logistic regression analysis showed that experienced discrimination was

independently and positively related to unemployment (0.61, 95% CI= 0.43-0.86). Other

variables that were significantly related to unemployment were ‘low educational level’ (0.48,

95% CI= 0.34-0.69) and ‘having ever been admitted to psychiatric treatment’ (0.55, 95% CI=

0.38-0.79).


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Discussion

The results of this study show that as many as 62.5% of participants reported to have

anticipated and/or experienced discrimination in the work setting. Anticipated

discrimination was reported more often than experienced discrimination. Participants from

countries with a very high HDI reported significantly more often anticipated and

experienced discrimination, although even in the medium/low HDI group, about one third of

participants reported discrimination in the work setting. Regarding the third research

question, it was found that experienced discrimination was indeed independently related to

unemployment.

These findings show that discrimination in the workplace is a common problem in

many countries worldwide. Considering that inpatients were excluded from the study, for

the total group of people with MDD these percentages may be even much higher. These

findings are consistent with those of a large Australian study on the experiences and

perspectives of people with MDD21

. Here, participants indicated that stigma was a

considerable problem, particularly regarding employment. In a similar German study, 81.5%

of the 55 participants who had experienced a depressive episode anticipated stigmatization

in the occupational setting22

. These studies from the depressed individual’s perspective are

in line with results of studies on employers’ perspectives. Such studies have shown that

employers tend to have negative attitudes towards people with mental health problems (5-7).

An important finding of the present study was that participants anticipated

discrimination more often than that they had actually experienced it. In another study, Ucok

et al. 8 found that anticipated discrimination was not necessarily associated with

experienced discrimination. Similar to our results, Angermeyer et al5 also found anticipated

discrimination to be higher than experienced discrimination, and suggest it could result in

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the tendency to avoid situations with a high risk of stigma. Corrigan and colleagues

described this “why try” effect as an overarching phenomenon encompassing self-stigma,

followed by low self-esteem and self-efficacy, and a diminished behavior to pursue life

goals23

. However, not only people with mental ill health themselves anticipate to be

discriminated in the workplace. A recent population-based survey of working adults in

Canada showed that a third of workers would not tell their managers if they experienced

mental health problems, mostly for fear of damaging their careers24

. Hence, findings from

these studies and this present study underline the clear need for interventions focusing on

the empowerment of people with MDD in the work environment. Peer support plays an

important role in enhancing empowerment and decreasing self-stigma 20

and may be useful

in such programs.

Because mental health problems are highly prevalent 13, 25

, but people with these

disorders are often reluctant to disclose their condition21, 22

, employers often are not aware

of the fact that many of their employees have mental health problems. Although this is a

major impediment for work adaptations, authors of a recent vignette study concluded that

concealment of mental health problems may actually be wise, as employers tended to think

more negatively about a worker with depression than with a physical disorder under the

exact same circumstances (26)

. Recently, a decision aid for employees on whether or not to

disclose their mental health problems to an employer has been developed 27-28

, that has

shown to effectively reduce decisional conflict in employees with mental health problems27

.

Future programs aimed at reducing stigma and discrimination, should also involve

employers and occupational health professionals as they play a major role in whether or not

temporary workplace reasonable adjustments or accommodations are made. Boot et al.

showed that workplace adjustments are associated with a reduction in sick leave duration

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and that 43% of workers with mental health problems reported a need for work

adjustments29

.

Results of the present study indicated that in very highly developed countries,

significantly higher percentages of discrimination were reported as compared to countries

with a low/medium developmental score (research question 2). These findings differ from

those of an intercultural study on employers’ attitudes towards hiring and accommodating a

person with disabilities at work10

. Here, it was found that Chinese employers were less likely

to endorse hiring people with psychiatric disabilities than employers from the US or Hong

Kong. However, it should be noticed that within one HDI group, many different countries

and cultures are represented which limits generalizability.

Whereas the size of the present study, including 35 countries, is a considerable

strength, the number of people interviewed per country was too small to draw any

conclusions at country level. Nevertheless, the results indicated that even in countries with

a medium to low developmental score, about one third of participants reported

discrimination in the work setting. Future research should focus on differences between

countries, and study for instance the effects of legislation. However, legislation will not

entirely solve the problem, as it does not address self-stigma.

We also found that experienced discrimination was significantly related to

unemployment (research question 3). These findings are similar to those of a large

household interview survey in six European countries. Specifically, they found that in

participants with a mental health problem, perceived stigma was not only significantly

associated with being unemployed, but also with a decreased quality of life, higher work

and role limitations and higher social limitations30

. An explanation for the finding that

experienced discrimination was independently related to unemployment is that the social

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stigma attached to mental health problems amongst employers may hinder them to hire an

employee with MDD11,26

. Alternatively this finding may be explained by the fact that during

job interviews, applicants with MDD may not get the position because MDD is characterized

by a variety of symptoms that may be disadvantageous during job interviews, such as

markedly diminished interest in activities, impaired ability to think, concentrate or make

decisions, fatigue, increased irritability, and low self-worth20

. These symptoms may

influence both applicants’ verbal and nonverbal behavior, thereby diminishing their chances

of being appointed.

When considering the results of this study, several limitations need to be taken into

account. First, apart from the four items on the DISC questionnaire that measured

anticipated and experienced discrimination, little additional information was available on

how participants perceived their work setting and why they felt discriminated. Future

qualitative and longitudinal studies are needed to address this in more detail, focusing on

the role of stakeholders such as supervisors, employers, colleagues and occupational health

professionals. A second limitation is that the design of the study was cross sectional, for

which reason no causality can be assumed. Hence, discrimination may lead to

unemployment, but unemployment may also lead to feelings of being discriminated against.

Third, purposive sampling was used to recruit participants. This limits the generalizability of

the results, as participants do not necessarily represent true prevalent cases in the

community.

In conclusion, the results suggest that anticipated and experienced discrimination in

the workplace is a highly common phenomenon in higher as well as in lower developed

countries across the world. The topic of overcoming stigma and discrimination has been

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under-researched so far31

but may offer new ways to improve work participation of people

with MDD. In many countries mental health problems such as MDD are associated with high

costs for society, due to unemployment, absences and at work performance deficits 32-34

.

Previous studies have called for research addressing workplace environment issues to

improve work participation of people with MDD32,34

. Stigma and work place discrimination

are such issues and there is a clear need for effective interventions.

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Table 1. Characteristics of the sample (N=834)

Demographic characteristics

Age (mean, SD) 42.7 (11.9)

Female gender (%) 66.9

Education (%)

None, primary (age ≤12), secondary (≤15-16 years), or vocational

qualification

Diploma, degree, or postgraduate qualification

43.8

56.2

Marital status (%)

Married or cohabiting

Single or non-cohabiting partner

Widowed, separated, divorced

52.2

25.9

21.7

Belongs to ethnic minority (%) 8.2

Human Development Index score1

Very high HDI countries

High HDI countries

Medium HDI countries

Low HDI countries

47.0

28.2

14.0

10.8

Mental health characteristics

Ever admitted for psychiatric care (%) 36

Age first contact with mental health services (mean, SD) 33.6 (11.8)

Internalized stigma total score2

(mean, SD) 2.4 (0.55)

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Work related characteristics

Employment

Full-time or part-time

Volunteer, or working in a sheltered accommodation or at home

Looking for a job

Unemployed, not looking for a job3

51.2

13.1

14.4

21.3

1HDI, United Nations Development Programme

19

2Total score on the Internalized Stigma of Mental Illness scale

20. Scale ranges from 1-4,

higher scores indicating higher internalized stigma.

3Combination of ‘Would like to work but afraid to loose benefits’, ‘unable to work’, ‘choose

not to work’.

Table 2. Responses to the DISC-121 questions related to employment (N=834)

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19

N (%)

Anticipated discrimination

…have you stopped yourself from applying for work?

not at all

a little

moderately

a lot

not applicable

…have you stopped yourself from applying for education or training

courses?

not at all

a little

moderately

a lot

not applicable

338 (40.5)

63 (7.6)

65 (7.8)

109 (13.1)

239 (28.7)

373 (44.7)

72 (8.6)

39 (4.7)

67 (8.0)

262 (31.4)

Experienced discrimination

… have you been treated unfairly in finding a job?

not at all

a little

moderately

402 (48.2)

41 (4.9)

35 (4.2)

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20

a lot

not applicable

… have you been treated unfairly in keeping a job?

not at all

a little

moderately

a lot

not applicable

45 (5.4)

307 (36.8)

423 (50.7)

61 (7.3)

57 (6.8)

77 (9.2)

213 (25.5)

1Discrimination and Stigma Scale.

17

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Figure 1. Percentages of respondents who reported to have anticipated and experienced

discrimination in the work setting, in very high, high, moderately and lower developed

countries.

0

10

20

30

40

50

60

70

Very high HDI High HDI Medium/Low

HDI

Pe

rce

nta

ge



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Table 3. Multivariable logistic regression analysis work status. Dependent variable was

work status.

Univariable models Multivariable model

Odds ratios (95% CI) Odds ratios (95% CI)

Experienced discrimination 0.63 (0.45-0.88)** 0.61 (0.43-0.86)**

Female gender 0.68 (0.50-0.92)* 0.79 (0.55-1.14)

Age 0.99 (0.97-1.00)* 0.99 (0.98-1.01)

Ethnic minority 0.88 (0.50-1.55) -

Low level of education 0.44 (0.33-0.59)** 0.48 (0.34-0.69)**

Marital status



Widowed, separated, or divorced

Ref

0.72 (0.50-1.03)

0.86 (0.61-1.21)

-

Ever admitted for psychiatric treatment 0.61 (0.45-0.84)** 0.55 (0.38-0.79)**

Age first contact with mental health

services

1.00 (0.99-1.01) -

ISMI total 0.66 (0.50-0.86)** 0.72 (0.52-1.00)

HDI

Low / Medium HDI countries

High HDI countries

Very High HDI countries

Ref

1.43 (0.71-2.85)

1.34 (0.71-2.50)

-

* p<0.05

** p<0.01

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Contributorship statement: The original study design and protocol were written by AL, TVB,

and GT. AL, TVB, CB, KW, CVA, JVW, IM and GT coordinated data gathering in the

participating sites. EB, JvW, JM AL and CB participated in the data analysis and

interpretation. The report was written by EB, JVW, JM, TVB GT and was edited by all authors,

who also approved of the final version.

Competing interests: none

Funding: This report arises from the project Anti Stigma Programme European Network

(ASPEN) which has received funding from the European Union in the framework of the

Public Health Programme

Data sharing statement: The data were gathered by a consortium. Additional information

can be obtained by contacting dr Tine Van Bortel (PhD) [email protected]

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16. Thornicroft G, Brohan E, Rose D, et al. Global pattern of anticipated and experienced

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17. Brohan E, Clement S, Rose D, et al. Development and psychometric evaluation of the

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23. Corrigan PW, Larson J, Ruesch N. Self-Stigma and the "why-try" effect: impact on life

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26. Mendel R, Kissling W, Reichhart T, et al. Managers' reactions towards employees'

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representative sample of employees with a chronic disease in the Netherlands. J Occup

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30. Alonso J, Buron A, Rojas-Ferreras S, et al. Perceived stigma among individuals with

common mental disorders. J Affect Disorders. 2009;118:180-186.

31. Evans-Lacko S, Courtin E, Fiorillo A, et al. The state of the art in European research on

reducing social exclusion and stigma related to mental health: a systematic mapping of the

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32. Lerner D, Henke R. What does research tell us about depression, job performance,

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34. Lagerveld SE, Bültmann U, Franche RL, et al. Factors associated with work

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5

Objectives 3 State specific objectives, including any prespecified hypotheses 6

Methods

Study design 4 Present key elements of study design early in the paper 6

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

6

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 7

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

7

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

7/8

Bias 9 Describe any efforts to address potential sources of bias 14

Study size 10 Explain how the study size was arrived at 7

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

9

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 9

(b) Describe any methods used to examine subgroups and interactions 9

(c) Explain how missing data were addressed 7

(d) If applicable, describe analytical methods taking account of sampling strategy

(e) Describe any sensitivity analyses 10

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

10

(b) Give reasons for non-participation at each stage 7

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

17

(b) Indicate number of participants with missing data for each variable of interest 7

Outcome data 15* Report numbers of outcome events or summary measures 19

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

7

(b) Report category boundaries when continuous variables were categorized 7

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 11

Discussion

Key results 18 Summarise key results with reference to study objectives 12

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

15

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

15

Generalisability 21 Discuss the generalisability (external validity) of the study results 15

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

23

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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Discrimination in the workplace, reported by people with

major depressive disorder: Cross-sectional study in 35

countries.

Journal: BMJ Open

Manuscript ID bmjopen-2015-009961.R1

Article Type: Research

Date Submitted by the Author: 16-Nov-2015

Complete List of Authors: Brouwers, Evelien; Tilburg University, School of Social & Behavioral Sciences, Tranzo Mathijssen, Jolanda; Tilburg University, School of Social & Behavioral Sciences, Tranzo Van Bortel, Tine; King’s College London, Institute of Psychiatry Knifton, Lee; Mental Health Foundation, Wahlbeck, Kristian; National Institute for Health and Welfare, Audenhove, Chantal; Katholieke Universiteit Leuven, LUCAS Kadri, Nadia; Ibn Rushd University, Psychiatric Center Chang, Chih-Cheng; Chi Mei Medical Centre, Department of Psychiatry Goud, Ramakrishna; St John’s Medical College Hospital, St John’s National Academy of Health Sciences Ballester, Dinarte; Sistema de Saúde Mãe de Deus, Tofoli, Luis Fernando; Universidade Federal do Ceara, Bello, Ricardo; Hospital Universitario de Caracas, Monteiro, Maria Fatima; Associacao para o Estudo e Integracao Psicossocial, Zaeske, Harald; Heinrich-Heine Universitaet, Rheinische Kliniken Dusseldorf Milacic, Ivona; University of Belgrade, Faculty for Special Education and Rehabilitation, Ucok, Alp; Istanbul University, Faculty of Medicine, Department of Psychiatry Bonetto, Chiara; University of Verona, Department of Public Health and Community Medicine, Section of Psychiatry Lasalvia, Antonio; University of Verona, Department of Public Health and Community Medicine, Section of Psychiatry Thornicroft, Graham; Kings College London, Institute of Psychiatry van Weeghel, Jaap; Tilburg University, School of Social & Behavioral Sciences, Tranzo

<b>Primary Subject Heading</b>:

Mental health

Secondary Subject Heading: Occupational and environmental medicine

Keywords: Depression & mood disorders < PSYCHIATRY, OCCUPATIONAL & INDUSTRIAL MEDICINE, discrimination, stigma, work, human development index


BMJ Open on S

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1

Discrimination in the workplace, reported by people with major depressive disorder:

Cross-sectional study in 35 countries.

Brouwers EPM1, Mathijssen J

1., Van Bortel T

2., Knifton L.

3, Wahlbeck K.

4, Van Audenhove C

5,

Kadri N6, Chang Ch

7, Goud BR

8, Ballester D

9, Tófoli LF

10, Bello R

11, Jorge-Monteiro MF

12,

Zäske H13

, Milaćić I14

, Uçok A15

, Bonetto C16

, Lasalvia A16

, Thornicroft G.2; Van Weeghel J.

1;

and the ASPEN/INDIGO Study Group*

1. Tilburg University, department Tranzo, The Netherlands

2. King’s College London, Institute of Psychiatry, London, UK

3. Mental Health Foundation, Glasgow, UK

4. National Institute for Health and Welfare, Vasa, Finland

5. Katholieke Universiteit Leuven, Leuven, Belgium

6. Ibn Rushd University Psychiatric Centre, Casablanca, Morocco

7. Chi Mei Medical Centre, Department of Psychiatry, Tainan, Taiwan

8. St John’s Medical College Hospital, St John’s National Academy of Health Sciences,

Bangalore, India

9. Sistema de Saúde Mãe de Deus, Porto Alegre, Brazil

10. Universidade Federal do Ceara, Campus Sobral, Brazil

11. Hospital Universitario de Caracas, Caracas, Venezuela

12. Associacao para o Estudo e Integracao Psicossocial, Lisbon, Portugal

13. Heinrich-Heine Universitat Dusseldorf, Rheinische Kliniken Dusseldorf, Germany

14. Faculty for Special Education and Rehabilitation, Belgrade, Serbia

15. Foundation of Psychiatry Clinic of Medical Faculty of Istanbul, Istanbul, Turkey

16. Department of Public Health and Community Medicine, Section of Psychiatry,

University of Verona, Verona, Italy

Corresponding author:

Evelien P.M. Brouwers, PhD

Tilburg University, School of Social and Behavioral Sciences, Department Tranzo, The

Netherlands. P.O. Box 90153, 5000 LE Tilburg. Tel: +31 (0)13 4662962

[email protected]

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Abstract

Objective

Whereas employment has shown to be beneficial for people with Major Depressive Disorder

(MDD), across different cultures, employers’ attitudes have shown to be negative towards

workers with MDD. This may form an important barrier to work participation. Today, little is

known about how stigma and discrimination affect work participation of workers with MDD,

especially from their own perspective. We aimed to assess, in a working age population

including respondents with MDD from 35 countries: (1) if people with MDD anticipate and

experience discrimination when trying to find or keep paid employment; (2) if participants in

high, middle and lower developed countries differ in these respects; and (3) if discrimination

experiences are related to actual employment status (i.e. having a paid job or not).

Method

Participants in this cross-sectional study (N=834) had a diagnosis of MDD in the previous 12

months. They were interviewed using the Discrimination and Stigma Scale (DISC-12).

ANOVAS and generalized linear mixed models were used to analyze the data.

Results

Overall, 62.5% had anticipated and/or experienced discrimination in the work setting. In

very high-developed countries almost 60% of respondents had stopped themselves from

applying for work, education or training because of anticipated discrimination. Having

experienced workplace discrimination was independently related to unemployment.

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Conclusions

Across different countries and cultures, people with MDD very frequently reported

discrimination in the work setting. Effective interventions are needed to enhance work

participation in people with MDD, focusing simultaneously on decreasing stigma in the work

environment and on decreasing self-discrimination by empowering workers with MDD.

Keywords: discrimination, stigma, depression, mental, employment, work, workplace,

human development index

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Strengths and limitations

• Depression is the leading cause of disability worldwide, and for this study

respondents with major depressive disorder from as many as 35 countries were

interviewed.

• This study examines the under-researched yet substantial problem of discrimination

as a barrier for work participation of people with MDD.

• Interviews were used to gather direct self-reports rather than hypothetical scenarios

or vignettes, which is often done in research on stigma and discrimination

• Limitations are the cross sectional design of the study, and the fact purposive

sampling was used to recruit participants, which limits the generalizability of the

results.

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Introduction

Employment has many benefits that can contribute to the recovery of people with

mental health problems 1, 2

. However, in many countries participation and re-integration of

people with mental health problems in the workforce is problematic 3, 4

. Several factors

cause this. Some are related to the individual, and some to the environment. An important

barrier for full occupational participation and successful vocational integration is the stigma

that is associated with mental health problems5. Stigma is a mark or sign of disgrace usually

eliciting negative attitudes to its bearer and can be seen as a problem associated with

knowledge (ignorance), attitudes (prejudice) and behavior (discrimination)6. Several studies

have shown that although some cultural differences may exist7, overall employers in many

countries commonly express a range of concerns about hiring a potential employee with

mental health problems 8-10

. Concerns reported include the belief that people with mental

health problems have limited productivity and job performance, especially in tasks requiring

cognitive skills 8, 11

, that they are unreliable and might pose threats to the safety of other

employees, customers or themselves11

, or behave in a strange and unpredictable manner,

and that there is potential for symptom relapse 8. In addition, the anticipation of

discrimination by people with MDD may lead them not to apply for a job, in the expectation

of failure or rejection.

Whereas most studies on mental health problems and discrimination in the

workplace have focused on severe mental disorders such as schizophrenia, relatively few

have focused on major depressive disorder (MDD)5. This is remarkable, as MDD is one of the

leading causes of the global burden of disease12

. It is one of the most prevalent of all causes

of disability 13, 14

and therefore an important public health problem. Across different

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countries and cultures stigma and discrimination form an important barrier to work

reintegration, although this topic has hardly been studied. In this context, the aim of this

study was to assess: (1) if people with MDD of working age anticipate and experience

discrimination because of their mental health problems when trying to find or keep paid

employment; (2) if people with MDD of working age from high, middle and lower developed

countries differ in this respect; and (3) if discrimination experiences when trying to find or

keep paid employment are related to present work status (i.e. having a paid job) in working

aged people with MDD.

Methods

Study design

Data were gathered as part of a larger study by the European Commission funded ASPEN

(Anti Stigma Program European Network) study and the INDIGO (International Study of

Discrimination and Stigma for Depression) research network15

. In a cross-sectional survey,

people with a clinical diagnosis of major depressive disorder were interviewed in 35

countries. The ASPEN countries included Belgium, Bulgaria, England, Finland, France,

Germany, Greece, Hungary, Italy, Lithuania, The Netherlands, Portugal, Romania, Scotland,

Slovakia, Slovenia, Spain and Turkey. The countries participating through the INDIGO

network included Australia, Brazil, Canada, Croatia, Czech Republic, Egypt, India, Japan,

Malaysia, Morocco, Nigeria, Pakistan, Serbia, Sri Lanka, Taiwan, Tunisia and Venezuela.

The design of this study was intentionally pragmatic so that as many as possible low-

and middle-income countries could participate using only locally available resources,

because no external funding was available. Participants were recruited through local

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research staff, who were asked to identify people attending specialist mental health services

(either outpatient or day care in the public and private sectors) in the local area with a

clinical diagnosis of major depressive disorder in the previous 12 months. They were asked

to all apply the DSM-IV criteria in the same, traditional way. Within centers, site directors

were asked to identify a minimum of 25 participants who were, in their judgment,

reasonably representative (as a group) of all people with a diagnosis of MDD attending

specialist mental health services (either outpatient or day-care in both the public and

private sectors in the local area). The minimum number of 25 for each site was defined for

feasibility issues, particularly for non-European sites with no grant support. This method was

intended to allow local staff to take into account the specific local service configuration and

to draw participants from the whole range of appropriate local services. Staff at each site

ensured that the sample had a spread across adult age range [young people (18-25),

working years (25-65), older adults (≥65)] and clear representation of female participants as

MDD is twice as prevalent in women as men. Response rates were unknown. As the present

study focused on the working age population, students (N=72) and retired respondents

(N=168) were excluded from the analyses. Full details of the method have been previously

published15

.

Procedure

Data were gathered during face-to-face interviews in 2010, between January 1st

and

December 31st

. Inclusion criteria were (1) a clinical diagnosis of major depressive disorder

during the previous 12 months (single episode or recurrent), as based on the DSM-IV criteria;

(2) ability to speak and understand the main local language; and (3) aged 18 years or older.

Individuals who were receiving psychiatric in-patient care during recruitment were excluded.

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The study was approved by the appropriate ethical review board at each study site. After

complete description of the study to the subjects, written informed consent was obtained.

Measures

Participants were assessed face-to-face by independent researchers not involved in the care

process using the standardized Discrimination and Stigma scale (version 12), a structured

interview for recording the discrimination experienced by an individual with a mental health

problem 16, 17

. The DISC-12 interview starts with the statement “Discrimination and stigma

occur when people are treated unfairly because they are seen as being different from others.

This interview asks about how participants have been affected by discrimination and stigma

because of mental health problems”. The instrument consists of 32 questions, assessing

discrimination in several life domains, such as marriage, parenting, housing, and leisure. For

the present paper, only the items were that referred to discrimination in the work

environment are reported upon. For anticipated discrimination, the items used in this study

were: “Because of how others might respond to your mental health problem, have you

stopped yourself from applying for work?” and “Because of how others might respond to

your mental health problem, have you stopped yourself from applying for education and

training?”. For experienced discrimination, the items used were “Because of how others

might respond to your mental health problem, have you been treated unfairly in finding a

job?” and “Because of how others might respond to your mental health problem, have you

been treated unfairly in keeping a job?’. All questions were answered on a 4-point Likert

scale (0= not at all, 1= a little, 2=moderately, and 3= a lot).

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For the second research question, consistent with the methodology of a previous

ASPEN/INDIGO paper18

, countries were divided into groups according to the Human

Development Index (HDI). The HDI is a summary measure of human development

established by the United Nations19

, which measures the average achievements of a country

in three basic dimensions of human development: (a) long and healthy life (operationalized

as life expectancy at birth), (b) access to knowledge, (i.e the mean number of years of

schooling), and (c) standard of living, (i.e. gross national income per capita). As data were

gathered in 2010, the HDI statistic of that year was used. Countries with a very high HDI

score were England, Australia, Finland, Germany, Canada, Italy, Portugal, Belgium, France,

Japan, Greece, The Netherlands, Scotland, Slovakia, Slovenia, Spain, Czech Republic, Taiwan

and Hungary. Countries with a high HDI score were Turkey, Malaysia, Brazil, Serbia, Bulgaria,

Venezuela, Tunisia, Lithuania, Romania, and Croatia. As few countries had a low HDI, the

medium low and low HDI group were taken together as one group for the analyses. This

medium/low HDI group included Egypt, India, Morocco, Nigeria, Pakistan, and Sri Lanka.

Internalized stigma, one of the independent variables included in the analyses for

the third research question, was measured with the Internalized Stigma of Mental Illness

Scale (ISMI)20

. Internalized stigma refers to the inner subjective experience of stigma and its

psychological effects resulting from applying negative stereotypes and stigmatizing attitudes

to oneself. The ISMI is a 29-item instrument for self-rated assessment of the subjective

experience of stigma, with higher scores indicating higher internalized stigma. Here, the

total score on the ISMI was used.

Statistical analyses

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All analyses were performed using SPSS 19. All p values were two-tailed with an accepted

significance level of 0.05. For the first research question, percentages of anticipated and

experienced workplace discrimination were reported per country. For the second research

question, two separate ANOVAS were conducted, the first of which with anticipated

workplace discrimination as the dependent variable and HDI level as the independent

variable. A second ANOVA analysis was conducted with experienced workplace

discrimination as the dependent variable and HDI level as the independent variable. For the

first and second research questions, answers to the questions on anticipated and

experienced workplace discrimination were dichotomized into ‘No’ (“not at all”) and ‘Yes’

(“a little”, “moderately”, “a lot”). For the third research question, multivariate logistic

regression analysis was performed, using work status as the dependent variable, (defined as

0=no paid employment and 1=employed), and ten independent variables, including

experienced workplace discrimination. First, univariate analyses were conducted including

the following independent variables that were expected to be related to job outcome:

experienced workplace discrimination, gender, age, ethnicity (i.e. belonging to an ethnic

minority), level of education, marital status, previous psychiatric treatment, age of first

contact with mental health services, internalized stigma (ISMI total score), and HDI. Second,

all variables that showed a significant relationship with the dependent variable on a

univariate level (P<0.05) were included in the multivariable logistic regression analysis.

Results

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A total of 834 people with major depressive disorder across 35 different countries were

individually interviewed for this study. About half of all participants were married or

cohabiting, and two thirds of the participants were women. Characteristics of the sample

are shown in Table 1. Although there were differences in employment rate across sites, the

employment rates per HDI group did not differ significantly.


As shown in Table 2, for each separate question, about 40-50% of the participants indicated

that discrimination was not a problem for them. However, when looking at the 4 items

combined, about two thirds (62.5%) of the total sample reported anticipated and/or

experienced discrimination in the work setting due to their mental health problem. Almost

one third of participants indicated to have stopped themselves from applying for work

because of anticipated discrimination.


Regarding the second research question, significant differences were found between

the groups with different HDI levels. Specifically, participants in countries with a very high

HDI reported significantly more often anticipated (Χ2 = 26.01 (df=2), p<0.01) and also

experienced (Χ2 = 7.25 (df=2), p<0.05) discrimination than participants in countries with

moderate/low HDI (see Figure 1). As can also be seen from this Figure, in all three groups

the anticipated workplace discrimination scores were higher than the experienced

workplace discrimination scores.

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(Please insert Figure 1 about here)

Concerning the third research question, as can be seen in Table 3, several variables

were not related to work status on a univariate level (i.e. ‘belonging to an ethnic minority’,

‘marital status’, ‘age of first contact with mental health services’ and ‘HDI’), for which

reason they were not included in the multivariable model. Results from the multilevel

logistic regression analysis showed that experienced workplace discrimination was

independently and positively related to unemployment (0.61, 95% CI= 0.43-0.86). Other

variables that were significantly related to unemployment were ‘low educational level’ (0.48,

95% CI= 0.34-0.69) and ‘having ever been admitted to psychiatric treatment’ (0.55, 95% CI=

0.38-0.79).


Discussion

The results of this study show that as many as 62.5% of participants reported to have

anticipated and/or experienced discrimination in the work setting. Anticipated workplace

discrimination was reported more often than experienced workplace discrimination.

Participants from countries with a very high HDI reported significantly more often

anticipated and experienced workplace discrimination, although even in the medium/low

HDI group, about one third of participants reported discrimination in the work setting.

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Regarding the third research question, it was found that experienced workplace

discrimination was indeed independently related to unemployment.

These findings show that discrimination in the workplace is a common problem in

many countries worldwide. Considering that inpatients were excluded from the study, for

the total group of people with MDD these percentages may be even much higher. These

findings are consistent with those of a recent review21

and that of a large Australian study

on the experiences and perspectives of people with MDD22

. Here, participants indicated that

stigma was a considerable problem, particularly regarding employment. In a similar German

study, 81.5% of the 55 participants who had experienced a depressive episode anticipated

stigmatization in the occupational setting23

. These studies from the depressed individual’s

perspective are in line with results of studies on employers’ perspectives. Such studies have

shown that employers tend to have negative attitudes towards people with mental health

problems (5-7).

An important finding of the present study was that participants anticipated

workplace discrimination more often than that they had actually experienced it. In another

study, Uçok et al. 8 found that anticipated discrimination was not necessarily associated with

experienced discrimination. Similar to our results, Angermeyer et al5 also found anticipated

discrimination to be higher than experienced discrimination, and suggest it could result in

the tendency to avoid situations with a high risk of stigma. Corrigan and colleagues

described this “why try” effect as an overarching phenomenon encompassing self-stigma,

followed by low self-esteem and self-efficacy, and a diminished behavior to pursue life

goals24

. However, not only people with mental ill health themselves anticipate to be

discriminated in the workplace. A recent population-based survey of working adults in

Canada showed that a third of workers would not tell their managers if they experienced

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mental health problems, mostly for fear of damaging their careers25

. Hence, findings from

these studies and this present study underline the clear need for interventions focusing on

the empowerment of people with MDD in the work environment. Peer support plays an

important role in enhancing empowerment and decreasing self-stigma 20

and may be useful

in such programs.

Because mental health problems are highly prevalent 13, 26

, but people with these

disorders are often reluctant to disclose their condition21, 22, 27, 28

, employers often are not

aware of the fact that many of their employees have mental health problems. Although this

is a major impediment for work adaptations, authors of a recent vignette study concluded

that concealment of mental health problems may actually be wise, as employers tended to

think more negatively about a worker with depression than with a physical disorder under

the exact same circumstances 29

. Recently several studies have been conducted on the topic

of disclosure of mental illness in the workplace 21, 27,28,30.

For instance, a decision aid for

employees on whether or not to disclose their mental health problems to an employer has

been developed 31-32

, that has shown to effectively reduce decisional conflict in employees

with mental health problems31

. The findings of the present and other studies 21,25

suggest

that future programs aimed at reducing stigma and discrimination, should also involve

stakeholders from the environment such as employers and occupational health

professionals as they play a major role in for instance whether or not temporary workplace

reasonable adjustments or accommodations are made. Boot et al. showed that workplace

adjustments are associated with a reduction in sick leave duration and that 43% of workers

with mental health problems reported a need for work adjustments33

.

Results of the present study indicated that in very highly developed countries,

significantly higher percentages of workplace discrimination were reported as compared to

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countries with a low/medium developmental score (research question 2). These findings

differ from those of an intercultural study on employers’ attitudes towards hiring and

accommodating a person with disabilities at work10

. Here, it was found that Chinese

employers were less likely to endorse hiring people with psychiatric disabilities than

employers from the US or Hong Kong. However, it should be noticed that within one HDI

group, many different countries and cultures are represented which limits generalizability.

Whereas the size of the present study, including 35 countries, is a considerable

strength, the number of people interviewed per country was too small to draw any

conclusions at country level. Nevertheless, the results indicated that even in countries with

a medium to low developmental score, about one third of participants reported

discrimination in the work setting. Future research should focus on differences between

countries, and study for instance the effects of legislation. However, legislation will not

entirely solve the problem, as legislation does not address self-stigma, and also in countries

with more advanced equality legislation experienced workplace discrimination rates were

still high.

We also found that experienced workplace discrimination was significantly related to

unemployment (research question 3). These findings are similar to those of a large

household interview survey in six European countries. Specifically, they found that in

participants with a mental health problem, perceived stigma was not only significantly

associated with being unemployed, but also with a decreased quality of life, higher work

and role limitations and higher social limitations34

. An explanation for the finding that

experienced workplace discrimination was independently related to unemployment is that

the social stigma attached to mental health problems amongst employers may hinder them

to hire an employee with MDD11,29

. Alternatively this finding may be explained by the fact

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that during job interviews, applicants with MDD may not get the position because MDD is

characterized by a variety of symptoms that may be disadvantageous during job interviews,

such as markedly diminished interest in activities, impaired ability to think, concentrate or

make decisions, fatigue, increased irritability, and low self-worth20

. These symptoms may

influence both applicants’ verbal and nonverbal behavior, thereby diminishing their chances

of being appointed.

When considering the results of this study, several limitations need to be taken into

account. First, apart from the four items on the DISC questionnaire that measured

anticipated and experienced workplace discrimination, little additional information was

available on how participants perceived their work setting and why they felt discriminated.

Future qualitative and longitudinal studies are needed to address this in more detail,

focusing on the role of stakeholders such as supervisors, employers, colleagues and

occupational health professionals. A second limitation is that the design of the study was

cross sectional, for which reason no causality can be assumed. Hence, workplace

discrimination may lead to unemployment, but unemployment may also lead to feelings of

being discriminated against. Third, purposive sampling was used to recruit participants. This

limits the generalizability of the results, as participants do not necessarily represent true

prevalent cases in the community.

In conclusion, the results suggest that anticipated and experienced discrimination in

the workplace is a highly common phenomenon in higher as well as in lower developed

countries across the world. The topic of overcoming stigma and discrimination has been

under-researched so far35

but may offer new ways to improve work participation of people

with MDD. In many countries mental health problems such as MDD are associated with high

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costs for society, due to unemployment, absences and at work performance deficits 36-38

.

Previous studies have called for research addressing workplace environment issues to

improve work participation of people with MDD36,38

. Stigma and workplace discrimination

are such issues and there is a clear need for effective interventions.

Table 1. Characteristics of the sample (N=834)

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Demographic characteristics

Age (mean, SD) 42.7 (11.9)

Female gender (%) 66.9

Education (%)

None, primary (age ≤12), secondary (≤15-16 years), or vocational

qualification

Diploma, degree, or postgraduate qualification

43.8

56.2

Marital status (%)



Widowed, separated, divorced

52.2

25.9

21.7

Belongs to ethnic minority (%) 8.2

Human Development Index score1

Very high HDI countries

High HDI countries

Medium HDI countries

Low HDI countries

47.0

28.2

14.0

10.8

Mental health characteristics

Ever admitted for psychiatric care (%) 36

Age first contact with mental health services (mean, SD) 33.6 (11.8)

Internalized stigma total score2

(mean, SD) 2.4 (0.55)

Work related characteristics

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Employment

Full-time or part-time

Volunteer, or working in a sheltered accommodation or at home

Looking for a job

Unemployed, not looking for a job3

51.2

13.1

14.4

21.3

1HDI, United Nations Development Programme

19

2Total score on the Internalized Stigma of Mental Illness scale

20. Scale ranges from 1-4,

higher scores indicating higher internalized stigma.

3Combination of ‘Would like to work but afraid to loose benefits’, ‘unable to work’, ‘choose

not to work’.

Table 2. Responses to the DISC-121 questions related to employment (N=834)

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N (%)


…have you stopped yourself from applying for work?

not at all

a little

moderately

a lot

not applicable

…have you stopped yourself from applying for education or training

courses?

not at all

a little

moderately

a lot

not applicable

338 (40.5)

63 (7.6)

65 (7.8)

109 (13.1)

239 (28.7)

373 (44.7)

72 (8.6)

39 (4.7)

67 (8.0)

262 (31.4)


… have you been treated unfairly in finding a job?

not at all

a little

moderately

402 (48.2)

41 (4.9)

35 (4.2)

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a lot

not applicable

… have you been treated unfairly in keeping a job?

not at all

a little

moderately

a lot

not applicable

45 (5.4)

307 (36.8)

423 (50.7)

61 (7.3)

57 (6.8)

77 (9.2)

213 (25.5)

1Discrimination and Stigma Scale.

17

Figure 1. Percentages and 95% Confidence Intervals of respondents who reported to have

anticipated and experienced discrimination in the work setting, in very high, high,

moderately and lower developed countries.

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Table 3. Multivariable logistic regression analysis work status. Dependent variable was

work status, defined as working fulltime or parttime versus all other groups (looking for a

job, not looking for a job, volunteer work).

Univariable models Multivariable model

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Odds ratios (95% CI) Odds ratios (95% CI)


No

Yes

Ref

0.63 (0.45-0.88)**

Ref

0.61 (0.43-0.86)**

Sex

Male

Female

Ref

0.68 (0.50-0.92)*

Ref

0.79 (0.55-1.14)

Age 0.99 (0.97-1.00)* 0.99 (0.98-1.01)

Belongs to ethnic minority

No

Yes

Ref

0.88 (0.50-1.55)

-

Education

Diploma, degree, or postgraduate

qualification

None, primary (age ≤12), secondary

(≤15-16 years), or vocational

qualification

Ref

0.44 (0.33-0.59)**

Ref

0.48 (0.34-0.69)**

Marital status



Widowed, separated, or divorced

Ref

0.72 (0.50-1.03)

0.86 (0.61-1.21)

-

Ever admitted for psychiatric treatment

No

Ref

Ref

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Yes 0.61 (0.45-0.84)** 0.55 (0.38-0.79)**

Age first contact with mental health

services

1.00 (0.99-1.01)

-

ISMI total 0.66 (0.50-0.86)** 0.72 (0.52-1.00)

HDI

Low / Medium HDI countries

High HDI countries

Very High HDI countries

Ref

1.43 (0.71-2.85)

1.34 (0.71-2.50)

-

* p<0.05

** p<0.01

Contributorship statement: The original study design and protocol were written by AL, TVB,

and GT. AL, TVB, CB, KW, CVA, JVW, IM and GT coordinated data gathering in the

participating sites. EB, JvW, JM AL and CB participated in the data analysis and

interpretation. The report was written by EB, JVW, JM, TVB GT and was edited by all authors,

who also approved of the final version.

Competing interests: No, there are no competing interests.

Funding: This report arises from the project Anti Stigma Programme European Network

(ASPEN) which has received funding from the European Union in the framework of the

Public Health Programme

Data sharing statement: No additional data available.

Acknowledgement:

The ASPEN/INDIGO staff at coordinating centres: Graham Thornicroft, Tine Van Bortel,

Samantha Treacy, Elaine Brohan, Shuntaro Ando, Diana Rose (King’s College London,

Institute of Psychiatry, London, England); Kristian Wahlbeck, Esa Aromaa, Johanna Nordmyr,

Fredrica Nyqvist, Carolina Herberts (National Institute for Health and Welfare, Vasa, Finland);

Oliver Lewis, Jasna Russo, Dorottya Karsay, Rea Maglajlic (Mental Disability Advocacy Centre,

Budapest, Hungary); Antonio Lasalvia, Silvia Zoppei, Doriana Cristofalo, Chiara Bonetto

(Department of Public Health and Community Medicine, Section of Psychiatry, University of

Verona, Italy); Isabella Goldie, Lee Knifton, Neil Quinn (Mental Health Foundation, Glasgow,

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Scotland); Norman Sartorius (Association for the improvement of mental health

programmes (AMH), Geneva, Switzerland).

The ASPEN/INDIGO staff at partner centres: Chantal Van Audenhove, Gert Scheerder, Else

Tambuyzer (Katholieke Universiteit Leuven, Belgium); Valentina Hristakeva, Dimitar

Germanov (Global Initiative on Psychiatry Sofia, Bulgaria); Jean Luc Roelandt, Simon Vasseur

Bacle, Nicolas Daumerie, Aude Caria (Etablissement Public Sante ́ Mentale Lille-Me ́tropole

(EPSM/CCOMS), France); Harald Zaske, Wolfgang Gaebel (Heinrich-Heine Universitat

Dusseldorf, Rheinische Kliniken Dusseldorf, Germany); Marina Economou, Eleni Louki, Lily

Peppou, Klio Geroulanou (University Mental Health Institute (UMHRI (EPIPSI), Greece); Judit

Harangozo, Julia Sebes, Gabor Csukly (Awakenings Foundation, Hungary); Giuseppe Rossi,

Mariangela Lanfredi, Laura Pedrini (IRCCS Istituto Centro San Giovanni di Dio

Fatebenefratelli, Brescia, Italy; Arunas Germanavicius, Natalja Markovskaja, Vytis Valantinas

(Vilnius University, Lithuania); Jaap van Weeghel, Jenny Boumans, Eleonoor Willemsen,

Annette Plooy (Stichting Kenniscentrum Phrenos (KcP), The Netherlands); Teresa Duarte,

Fatima Jorge Monteiro (Associac ̧ a ̃ o para o Estudo e Integrac ̧ a ̃ o Psicossocial, Portugal);

Radu Teodorescu, Iuliana Radu, Elena Pana (Asociatia din Romania de Psihiatrie Comunitara,

Romania; Janka Hurova, Dita Leczova (Association for Mental Health INTEGRA, o. z.,

Slovakia); Vesna Svab, Nina Konecnik (University Psychiatric Hospital, Slovenia); Blanca

Reneses, Juan J Lopez-Ibor, Nerea Palomares, Camila Bayon (Instituto de Psiquiatria at the

Hospital Universitario San Carlos, Spain); Alp Ucok, Gulsah Karaday (Foundation of

Psychiatry Clinic of Medical Faculty of Istanbul (PAP), Turkey); Nicholas Glozier, Nicole

Cockayne (Brain & Mind Research Institute, Sydney Medical School, University of Sydney,

Australia); Luı ́s Fernando To ́foli, Maria Suely Alves Costa (Universidade Federal do Ceara ́,

Campus Sobral, Brazil); Roumen Milev, Teresa Garrah, Liane Tackaberry, Heather Stuart

(Department of Psychiatry, Queen’s University, Canada/Providence Care, Mental Health

Services, Kingston, Ontario, Canada; Branka Aukst Margetic, Petra Folnegovic Groiæ

(Department of Psychiatry, University Hospital Centre ZagrebMiro Jakovljeviæ, Croatia);

Barbora Wenigova ́, elepova ́ Pavla (Centre for Mental Health Care Development, Prague,

Czech Republic); Doaa Nader Radwan (Institute of Psychiatry, Ain Shams University, Cairo,

Egypt); Pradeep Johnson, Ramakrishna Goud, Nandesh, Geetha Jayaram (St. John’s Medical

College Hospital, St John’s National Academy of Health Sciences, Bangalore, India; Shuntaro

Ando (Social Psychiatry, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan;

Yuriko Suzuki, Tsuyoshi Akiyama, Asami Matsunaga, Peter Bernick (NTT Kanto Hospital,

Japan); Bawo James (Federal Neuropsychiatric Hospital, USELU, Benin City, Nigeria; Bolanle

Ola, Olugbenga Owoeye (Federal Neuropsychiatric Hospital Yaba, Lagos, Nigeria); Yewande

Oshodi (Department of Psychiatry, College of Medicine University of Lagos and Lagos

University Teaching Hospital, Lagos, Nigeria; Jibril Abdulmalik (Federal Neuropsychiatric

Hospital, Maiduguri, Nigeria); Kok-Yoon Chee, Norhayati Ali (Kuala Lumpur Hospital and

Selayang Hospital, Malaysia); Nadia Kadri, Dounia Belghazi, Yassine Anwar (Ibn Rushd

University Psychiatric Centre, Casablanca, Morocco); Nashi Khan, Rukhsana Kausar

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(University of the Punjab, Department of Applied Psychology and Centre for Clinical

Psychology, Lahore, Pakistan); Ivona Milacic Vidojevic (Faculty for Special Education and

Rehabilitation, Belgrade, Serbia); Athula Sumathipala (Institute of Psychiatry, King’s College

London/Institute for Research and Development, Sri Lanka); Chih-Cheng Chang (Chi Mei

Medical Centre, Department of Psychiatry, Tainan), Taiwan; Fethi Nacef, Uta Ouali, Hayet

Ouertani, Rabaa Jomli, Abdelhafidh Ouertani, Khadija Kaaniche (Razi Hospital Manouba,

Department of Psychiatry, Tunis, Tunisia); Ricardo Bello, Manuel Ortega, Arturo Melone,

Mar ́ıa Andre ́ına Marques, Francisco Marco, Arturo R ́ıos, Ernesto Rodr ́ıguez, Arianna

Laguado (Hospital Universitario de Caracas, Caracas, Venezuela). GT is supported by the

National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health

Research and Care South London at King’s College London Foundation Trust. The views

expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the

Department of Health. GT acknowledges financial support from the Department of Health

via the National Institute for Health Research (NIHR) Biomedical Research Centre and

Dementia Unit awarded to South London and Maudsley NHS Foundation Trust in

partnership with King’s College London and King’s College Hospital NHS Foundation Trust.

GT is supported by the European Union Seventh Framework Programme (FP7/2007-2013)

Emerald project.

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5

Objectives 3 State specific objectives, including any prespecified hypotheses 6

Methods

Study design 4 Present key elements of study design early in the paper 6

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

6

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 7

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

7

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

7/8

Bias 9 Describe any efforts to address potential sources of bias 14

Study size 10 Explain how the study size was arrived at 7

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

9

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 9

(b) Describe any methods used to examine subgroups and interactions 9

(c) Explain how missing data were addressed 7

(d) If applicable, describe analytical methods taking account of sampling strategy

(e) Describe any sensitivity analyses 10

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

10

(b) Give reasons for non-participation at each stage 7

(c) Consider use of a flow diagram

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

17

(b) Indicate number of participants with missing data for each variable of interest 7

Outcome data 15* Report numbers of outcome events or summary measures 19

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

7

(b) Report category boundaries when continuous variables were categorized 7

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 11

Discussion

Key results 18 Summarise key results with reference to study objectives 12

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

15

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

15

Generalisability 21 Discuss the generalisability (external validity) of the study results 15

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

23

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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bmj open€¦ · 7. chi mei medical centre, department of psychiatry, tainan, taiwan 8. st john’s...

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